Lower limb ulcers

Question 1

What are ulcers?

Answer 1

abnormal breaks in the skin or mucous membrane

Question 2

What is the origin of most ulcers?

Answer 2

Venous origin

Question 3

Other than venous origin, what are the other causes of ulcers?

Answer 3

Arterial insufficiency or diabetic related neuropathy and rarely infection, trauma, vasculitis or malignancy

Question 4

if there is prolonged or excessive pressure a over a bony prominence what can this cause?

Answer 4

Pressure ulcers leading to skin breakdown and necrosis

Question 5

How can pressure ulcers be managed?

Answer 5

adequate mattresses to aid repositioning and good wound management

Question 6

How do venous ulcers appear?

Answer 6

shallow with irregular borders and a granulating base

Question 7

Where do venous ulcers usually arise?

Answer 7

Media malleolus

Question 8

What are venous leg ulcers prone to?

Answer 8

infection and then cellulitis

Question 9

What is the pathophysiology of venous ulcers?

Answer 9

valvular incompetence or venous outflow obstruction which leads to impaired venous return, venous hypertension causes trapping of the white blood cells in the capillaries and fibrin cuff forms hindering oxygenation, white blood cell become activated, release inflammatory mediators to resultant tissue leading to tissue injury, poor healing and necrosis

Question 10

What are the risk factors of venous ulcers?

Answer 10

increasing age, venous incompetence e.g. varicose veins, pregnancy, obesity, physical inactivity, leg injury or trauma

Question 11

What are the symptoms of venous ulcers?

Answer 11

painful, usually in the gaiter region of the legs, aching, itching bursting sensation

Question 12

What will venous ulcers look like?

Answer 12

leg oedema, venous insufficiency such as varicose veins, eczema, thrombophebitis, haemosiderin skin staining, lipodermatoscerlosis, atrophie blanche

Question 13

How are venous ulcers diagnosed?

Answer 13

clinically but can be confirmed by duplex ultrasound

Question 14

What junctions fo venous insufficiency usually occur?

Answer 14

Sapheno-femoral or sapheno-popliteal junctions

Question 15

What does ABPI stand for?

Answer 15

The ankle brachial pressure index

Question 16

What does the ABPI do?

Answer 16

assess for any arterial component to the ulcers and determine whether compression therapy will be suitable

Question 17

If there is a suspected infection of the venous ulcer, how would this be confirmed?

Answer 17

microbiology swabs and swab cultures

Question 18

What is the management for venous ulcers?

Answer 18

leg elevation, increased exercise, (promote calf muscle pump action and increases venous return), lose weight and improve nutrition, multicomponent compression bandaging, also treat any varicose veins

Question 19

What is an arterial ulcer?

Answer 19

An ulcer caused by a reduction in arterial blood flow, causing decreased perfusion of the tissues and subsequent poor healing

Question 20

How do arterial ulcers usually form as?

Answer 20

Small deep lesions with well defined borders and a necrotic base

Question 21

Where do arterial ulcers usually form?

Answer 21

distally at sites of trauma and in pressure areas

Question 22

What are the risk factors for arterial ulcers?

Answer 22

peripheral arterial disease, smoking, diabetes mellitus, hypertension, hyperlipidaemia, increasing age, positive family history, obesity and physical inactivity

Question 23

What are the clinical features of arterial ulcers?

Answer 23

intermittent claudication (pain when walking) or critical limb ischaemia (pain at night) previously, painful ulcers that develop over a long time with little to no healing, cold lumps, thickened nails, necrotic toes and hair loss, reduced or absent pulses, if only arterial then sensation should be present

Question 24

What are the investigations for arterial ulcers?

Answer 24

Ankle brachial pressure index measurement which can then quantify the extent of any peripheral disease , duplex ultrasound, CT angiogram and MRA

Question 25

What is the management for arterial ulcers?

Answer 25

vascular review, lifestyle changes like smoking, weightless, exercise, statin therapy, anti platelets, blood pressure and glucose, angioplasty with or without spending and bypass grafting, skin reconstruction with grafts

Question 26

What are neuropathic ulcers?

Answer 26

ulcers that occur due to peripheral neuropathy, where there is a loss of protective sensation leading to repetitive stress ad unnoticed injuries forming, causing painless overs forming on the pressure points on the limb, vascular disease will contribute tot their formation and reducing healing potential

Question 27

What are the risk factors for neuropathic ulcers?

Answer 27

Diabetes mellitus and B12 defieciency, foot deformity or peripheral vascular disease

Question 28

What are the symptoms of neuropathic ulcers?

Answer 28

history of peripheral neuropathy, symptoms or peripheral vascular disease, burning and tingling in the legs (painful neropathy), single nerve involvement (mono neuritis multiplex such as CN III or median nerve), amotropic neuropathy (painful wasting of proximal quadriceps)

Question 29

What would be present on examination of neuropathic ulcers?

Answer 29

variable in size and depth with punched out appearance, there may be a peripheral neuropathy (glove and stocking distribution) warm feet and good pulses

Question 30

What investigations would be done for someone with neuropathic ulcers?

Answer 30

blood glucose levels, and B12 levels, ABPI and duplex, infection by swabs, X-ray to assess for osteomyelitis, asses peripheral neuropathy with 10g monofilament or ipswich test and vibration with 128Hz tuning fork

Question 31

What is the management for neuropathic ulcers?

Answer 31

diabetic foot clinic, diabetic control with HbA1c <7%, improved diet and increased exercise, cardiovascular risk managed and regular chiropody, antibiotics, surgical debridement if ischaemic or necrotic, may need amputation

Question 32

What is Charcots foot?

Answer 32

Neuroaarthropathy whereby loss of joint sensation resulting in continual unnoticed trauma and deformity, this predisposes the patient to neuropathic ulcer formation, there is swelling, distortion, pain, loss of function, rocker-bottom sole, may need off-loading abnormal weight to immobilisation

Question 33

what score of ABPI, bandaging be applied to a venous ulcer?

Answer 33

over 0.6